And just wait till you call in a day after the actual 6-month anniversary - "Sorry, but it's been longer than 6 months. We'll have to start with an original authorization. Please mail (no, fax is not acceptable, nor are email attachments) all original ...."

Friend of mine had a bad hip - doctor ordered an MRI. Insurance said no, not clinically indicated. They appealed, argued - nope. Finally they saved up and paid cash for the MRI - hey, what do you know, his hip was bad and he had it replaced yesterday - covered by insurance, and proven by the MRI that they wouldn't pay for. I give up.

and that's after waiting for 30 min for someone to pick up the freaking phone. NIA is the biggest piece of shit paid by the biggest pieces of shit to read off a script that all says the same thing: No.

I always like to note at times like that : Just because you have a Dr. or Judge in fromt of your name and you are given a job to do it does not mean that the laws of common sense are suspended in your case.

And I do ask for a common sense approach to bureaucratic conundrums with about a 50% success ratio and a 50% swearing under my breath ratio.

Just another way for insurance companies to slither out of not paying for something. I also love when they throw in the little disclaimer-"Just because something is prior authorized does not guarantee payment".

If it's any consolation, patients get even more of a run around. Promises of "You can use any physician of your choice." when you are choosing an insurance company means that you can choose one of the three faceless names who share a facility 35 miles across town and no one else, even though you have to drive by at least two dozen medical complexes and six hospitals to get there.

I suspect I will get pilloried for this, but from the insurance company's perspective, they are just keeping costs low so that they can offer competitive prices to their customers. Consumers *could* opt to pay more for insurance that didn't try to screw with customers on the back end. An insurance company has little incentive to offer no-hassle insurance because (many) people prefer to pay less, and hedge their luck on not getting sick. Such people don't consider the price of time on the phone arguing with an insurance company when they are selecting plans each year. Or perhaps they *do* consider the cost of time and aggravation, and factor it into their purchase.

Ibee, please. This post is pretty obvious. I am not even sure why you made the call, let alone this post. Insurance companies are going to wiggle any way they can. Like someone else said, a day late and it's no longer a followup. But I am sure you'll post that too.

It's the way insurance companies are designed. They take in premiums, spend some of the money on expenses and invest the rest while waiting to pay it out in claims.

The longer they can delay paying for things, the longer they are investing and the better it is from their perspective.

Unless they're forced to pay doctors by the minute for the time they spend making calls to get authorizations or appeal denials, it's in their advantage to create systems that make patients and physicians wait.

It's not always that goofy. My phlebotomist told me I had to wait until 30 days had elapsed for my standing order monthly blood draw, but I looked at the fine print on the back of the form and showed him that "monthly" means 25 to 31 days.

Gotta agree with the above post that said that this is what you get when health care is ALL about profit and NOT about patient care.

I also agree with the British person, I would rather have a single payer system than the total BS we have in the U.S.

STORY time: Had a friend who had severe back pain for six months and had been sent to PT. Insurance company would not approve an MRI, partly related to unscrupulous Ohio docs who owned MRI machines and were sending patients for unnecessary MRIs to get kickbacks. A few went to prison, no joke.

Friend's pain ebbed and flowed. She woke up one Sunday and was literally screaming into a pillow, the pain had become so bad. It later improved a little though.

By the next morning she could not pick up her baby nd was peeing on herself. Later she could not feel if she had to have a BM. Stupid insurance company STILL would not allow her PCP to order an MRI.

He was PISSED. Said to insurance rep, this patient and her husband are both attorneys. I am trying to order an MRI and you will not precert it. I am telling them NOT to sue ME, as I am trying to do my job, but that they can sue YOU, becasue you will not let me and hung up.

Count 'em. Less than three minutes later, the PCP gets a return call form the insurance company preapproving the MRI.

She has the MRI at 11:00 p.m. that night and they have her in for surgery at 6:00 a.m. the next morning, as a herniated disc was impining on her spinal cord badly.

This is the total freaking crap we have with FOR PROFIT medicine, led by diagnosis related group billing. Send them out bleeding, make tons of money and keep the CEOs RICH, yee hah. I work in health care, have for mnay years, but used to work in a law school.

Packer, never ever thought I would say this but THANK GOD for lawyers. Sorry kids, but I am welcoming Obama care. Gee the ONLY western nation that does NOT provide health care for its own citizens. Can we all say "pre-existing condition."

When I graduated pharmacy school in 1988 at the age of 30 with a husband and 9-year old son, my first job was a residency in a government facility, and I knew I wouldn't qualify for benefits though I knew I'd be working much more than 40 hours a week. I asked my doctor what kind of health insurance I should get since we would be moving away, and she would no longer care for my family, with our cash payment plan with its minimal well-care visits, and call her up in the middle-of-the-night in case it's meningitis strategy. She warned me that once we applied for it and were approved that I should always pay ahead and never allow it to lapse as I wasn't going to get another one because of the brain tumor in high school was a pre-existing condition. Despite the fact that the benign tumor was successfully removed, and I had been able to handle pharmacy school (dropping out 5 years when my child was born), I would not be able to afford the insurance. The health insurance became the motivation to hold full-time jobs after that. The fittest survive was clearly the case before my own family could afford to pay for employer-group health plans for catastrophic and health insurance.

I find it disingenuous for Pam to suggest that things will 'get worse' as the Affordable Healthcare Act is implemented, and that a physician advertises repealing Federal Law with nothing else on the table.

When Medicare reimbursement rates provided the minimum mark-up for prescriptions and seven family-owned pharmacies closed promptly (and were bought up by the chains who can afford to sell their deep discount drugs for less than cost--at one time this was illegal, but not anymore) while the doctors threatened to not take patients whose method of payment for their own care was Medicare. Squeaky wheels get the grease.

Ridiculousness of the PA has been around for a very long, long and tiresome amount of time. It's just that much more brazen when the interchange of denial is between physicians.

We can't believe our colleagues would go against the 'do no harm' creed that we all practice, and wonder who is passing out the licenses. Did they come from Crackerjack boxes?

The other day I called a local chain drug as part of my line of work in attempting to establish correct reconciliation records for medications when admitted to the hospital. I didn't recognise 'Ben' the pharmacist on the other line. He said he was busy and and when I suggested he fax the patient's list, he said he couldn't because of HIPAA. Teachable moment for a new grad. 'Look here, Ben. HIPAA is for health insurance companies that want to sell patient information drug companies and others that want to solicit patient business. We are working for the higher calling to benefit of the same patients. We are both pharmacists. If anyone has a right to know what the patient is taking, when, where, and how, it is me. Here is my fax number. If you are busy, please, ask your technician when she has a chance."

Anon, your orthopod is a retard and needs to stfu. He has no idea what really happens in insurance companies and his stupid is showing.

I work for Big Dough Health Insurance, Inc, and I am licensed, board certified RN with 15 years experience and nary a blemish on her record. All of our medical directors are board certified in their area of specialty, and our most recently hired one left his position at a teaching hospital to come over to the "dark side." IMHO, that's hardly evidence of being unable to hack it in the real world.

Also of note is that while there is certainly an area that reviews/approves/denies claims & procedures, that is by no means the only role that clinicians play in managed care.... I haven't approved OR denied a single claim/procedure/prior auth/appeal or ANYTHING in the time that I've been there. It may be surprising to many, but there are programs that interface directly with the enrolled members to help them improve their individual health. Is it a cost-containment program? You betcha! But I also think it a win-win situation as the members truly do reap concrete, measurable health benefits such as improved BP readings, improved medication compliance etc.

Final thought is that it's not always the insurers money on the table....in the event of a self-funded group, it's really the employer group's, and they are often the ones that set levels of cost sharing, prior authorizations, coverage exclusions etc etc etc.

I am by no means saying there aren't downsides to managed care, because there certainly are, and I could probably spit out a list of 25 issues not known by the lay public in less than 10 seconds, but there's absolutely no need to attack the clinicians working there, nor to suggest their abilites are less than their peers.

Hey, wait just one more %*#@ freakin' minute before stepping off the pedestal 'ahem', SOAPBOX.

Turf-war time.

Firstly, am personally experiencing a distinctly sinking (great sucking sound) cringe to think that a 'fully qualified RN for 15 years' has ANYTHING to do with countermanding a doctor's order in determining the fate of prior authorization of doctors' orders.

Do you mean to tell us that after a 2-yr (minimum) RN license and 15 years nursing experience this qualifies as being able tell a 10-yr+ (minimum) MD and 15 years physician experience and a 6-yr+ (minimum) RPh (PharmD) and 15 years pharmacist experience 'NO' as in, "prior authorization is denied"?

Secondly. If the authority to make the decision is based mainly on a qualified physician's guidance, where does the individual physical examination by the qualified physician come into making the appropriate decision such as Dr. Grumpy is fighting for and demonstrating the lack of common-sense in this vignette?

Speaking from personal experience, when the hospital insurance my employer received special discount for our members' participation decided to say 'NO' to continued care, the bottom line was based on a 'physician specialist' reading the charting notes that the actual examiner provided, with regard to a set of guidelines voted upon by MBAs, MDs, etc.. Of course that system has been on-going ever since there has been insurance adjudication.

The problem of adjudication will continue to persist no matter if there's government-funded (YES, we tax-payers most visibly provide input, and not the excuse of 'satisfying the stockholders') versus any other scheme (in which WE tax-payers less visibly, but even less transparently the stockholder do hold the reign in private-funded consortiums).

And, third, but not least. It doesn't do us as healthcare consumers to personally attack individual adjudicators, but there is no ethical way to deny continued coverage in a tertiary care facility if there is insufficient on non-existent intermediary care with many medical illnesses. This model is for a war, for which patient may have access to the most intensive therapy to survive, as is the case with mental illnesses which encompass the most treatable illness (with higher 'manageability' than all cardiac illnesses combined, yet are of higher costs exponentially than any other broad type of disease.

My ENT told me that he needed an MRI for a patient, and was denied by the insurance company because some other diagnostic test hadn't been done first, but he felt that SODT wasn't needed because of obvious symptoms.

He spent about 20 minutes on the phone with an insurance doctor arguing about the need for the MRI, with the insurance doc holding fast in the face of what my ENT thought was obvious evidence.

Finally, my ENT though to ask whether the insurance doc was an ENT, and he responded, "No, I'm a cardiologist." He was unfamiliar with what my ENT was trying to treat, the symptoms and the treatment, but was fighting tooth and nail against the MRI because his script told him the MRI shouldn't happen without SODT first.

I'm surprised that any doctors continue to practice medicine in the face of such BS.

Oh, for Pam's sake, I'll just leave this here:http://www.philly.com/philly/blogs/fieldclinic/The-best-health-insurance-in-America-is-government-health-insurance.html

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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